Perinatal substance use disorder: Examining the impact on adverse pregnancy outcomes.

Objective: Substance use disorder is a growing concern in the USA, especially among pregnant women. This study was undertaken to assess the impact of substance use disorder on adverse pregnancy outcomes using a nationwide sample of inpatient pregnancy hospitalizations in the USA, and to elucidate the influence on each type of adverse pregnancy outcome. Study design: A cross-sectional analysis of inpatient pregnancy hospitalizations in the USA from the Healthcare Cost and Utilization Project National Inpatient Sample from 2016 to 2020 was conducted. International Classification of Diseases - 10th revision and diagnosis-related group codes were used to identify inpatient pregnancy-related delivery hospitalizations with a substance use disorder and/or adverse pregnancy outcomes. Propensity score matching and multiple logistic regression analyses were undertaken to predict the likelihood of adverse pregnancy outcomes among pregnancy hospitalizations with and without substance use disorder. Subgroup analyses were performed to estimate the impact of substance use disorder on each adverse pregnancy outcome. Results: From 3,238,558 hospitalizations, the prevalence of adverse pregnancy outcomes was substantially higher among pregnancy hospitalizations with substance use disorder (35.6 %) compared with pregnancy hospitalizations without substance use disorder (25.1 %, p < 0.001). After matching and model adjustment for sociodemographic covariates, substance use disorder was identified as an independent predictor of adverse pregnancy outcomes [adjusted odds ratio (aOR) 1.47, 95 % confidence interval (CI) 1.45-1.49]. In subgroup analyses based on type of adverse pregnancy outcome, the greatest exposure risks were fetal growth restriction (aOR 1.96, 95 % CI 1.91-2.01), antepartum hemorrhage (aOR 1.79, 95 % CI 1.73-1.85) and preterm birth (aOR 1.65, 95 % CI 1.62-1.68). Conclusion: Patients with substance use disorder are at higher risk of adverse pregnancy outcomes, particularly fetal growth restriction, antepartum hemorrhage and preterm birth.

The Importance of Fetal Station in the First Stage of Labor.

OBJECTIVE: This study aimed to examine the relationship of fetal station in the first stage of labor to labor curves and cesarean delivery rates among women presenting in spontaneous labor. STUDY DESIGN: Labor curves for patients with nonanomalous singletons who presented in spontaneous labor to our hospital's Obstetric Triage Unit with intact membranes from January 1, 2012, to August 31, 2016 were reviewed. Cervical exams and time of exam were obtained for each patient from presentation to triage until delivery. Station for each presentation and cervical dilation was estimated using a random effects model and the slope of cervical station change was calculated to estimate the change in dilation by hour. Perinatal outcomes, including cesarean delivery rates, were examined according to fetal station at initial presentation. Factors known to affect labor curves-epidural analgesia, infant birthweight, maternal habitus, and parity-were also examined. RESULTS: There were 8,123 patients presented in spontaneous labor with intact membranes. For patients presenting at 6-cm dilation, the rate of change of labor was significantly different when identified to have a station greater than 0 (+1 and more caudad) when compared with those with -1 and more cephalad station (both p < 0.001). This relationship persisted when analyzed according to epidural analgesia, birthweight, maternal habitus, and parity. The frequency of cesarean delivery was significantly higher for women presenting in spontaneous labor with negative fetal station (p < 0.05). When stratified across all dilation (3-9 cm), this trend remained significant (p < 0.001). CONCLUSION: In the first stage of labor, advanced fetal station was significantly associated with differing rates of labor progression, and positive fetal station was significantly less likely to result in cesarean delivery. Physical examination, including station, remains a critical element in labor management. KEY POINTS: · Fetal station is important in labor management.. · Fetal station at initial exam is related to time to delivery.. · Positive fetal station at initial exam is less likely to result in cesarean delivery..

Racial and Ethnic Disparities Among Pregnancies with Substance Use Disorder: Impact on Perinatal Outcomes.

Objective: To examine racial/ethnic disparities in severe maternal morbidity (SMM) and adverse pregnancy outcomes (APOs) among pregnant patients with substance use disorder (SUD) compared to individuals without SUD. Materials and Methods: We conducted a cross-sectional analysis of inpatient hospitalizations of pregnant people from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2016 to 2019. ICD-10 codes were used to identify the frequency of SMM and/or APO between those with and without SUD by race/ethnicity. Multilevel logistic regression analyses were performed to identify the effect of race/ethnicity as an independent predictor and as an effect modifier of SMM and APO in patients with SUD. Results: From 2,508,259 hospitalizations, SUD was identified in 6.7% admissions with the highest rate in White patients (8.2%) followed by Black (7.7%) and Hispanic (2.2%) patients. Rate of SMM and APO were increased in patients with SUD in all racial/ethnic groups compared to those without SUD, increasing by 1% and 10%, respectively. Among all patients, Black race was an independent predictor of SMM (adjusted odds ratio [aOR] 2.09; 95% confidence interval [CI]: 2.05-2.13) and APO (aOR 1.58; 95% CI: 1.56-1.59). Hispanic ethnicity was also an independent risk factor for predicting SMM (aOR 1.40; 95% CI: 1.37-1.43). Among Hispanic patients, SUD was associated with an ∼90% increased likelihood of SMM and APO. Conclusion: Although higher rates of SMM and APO are seen among hospitalizations of pregnant people with SUD, racial/ethnic disparities also exist among this population. This warrants further attention and presents an opportunity for intervention and for addressing the root causes of racial and ethnic disparities.

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People.

Importance: Postpartum transfusion is the most common indicator of severe maternal morbidity in the US. Higher rates of anemia are associated with a higher blood transfusion rate. Objective: To determine if providing, rather than recommending, supplements with iron at prenatal visits in a medically underserved community is associated with improved hematologic indices and reduced blood transfusion. Design, Setting, and Participants: In this quality improvement study, patients who delivered between May 13 and December 13, 2020, and thus were provided a prenatal supplement with iron throughout pregnancy were compared with those who delivered between January 1 and August 1, 2019, before supplements were dispensed. The study was conducted at Parkland Health, a safety net hospital in Dallas, Texas, with a 95% Medicaid-funded or self-pay population and included all patients who delivered at our institution during the study period with available hematologic data. Exposures: In the earlier cohort, all patients were recommended to obtain and take iron supplements. In the later cohort, prenatal supplements with iron were dispensed via clinic pharmacy to all patients during prenatal visits. Main Outcomes and Measures: Maternal hematocrit levels (28-32 weeks, delivery admission, and discharge), rates of anemia (hematocrit <30%), and postpartum transfusion for acute blood loss anemia were compared using χ2 and analysis of variance methods with P < .05 considered significant. The analysis took place in July of 2022. Results: Overall, 13 910 patients (98%) met inclusion criteria (mean age [SD], 27.9 [6.5] and 27.6 [6.5] years, mean [SD] body mass index at first visit, 29.2 [6.6] and 29.3 [6.6]). Mosty of the patients in both cohorts were of Hispanic ethnicity (76%). Providing iron-containing prenatal supplements was associated with higher average hematocrit levels at all time points including a mean difference of 1.27% (95% CI, 1.13%-1.42%) on admission for delivery, when compared with those who were not directly dispensed iron. Among patients prior to providing supplements, 18% had anemia on admission compared with 11% with iron-containing supplements dispensed (risk ratio [RR], 0.61; 95% CI, 0.56-0.66). Postpartum transfusion for acute blood loss anemia was reduced by one-third in patients after program implementation from 10 per 1000 to 6.6 per 1000 (RR, 0.62; 95% CI, 0.43-0.91). Conclusions and Relevance: In this quality improvement study, providing supplements with iron to patients at prenatal visits was associated with improved hematocrit levels, rates of anemia, and reduced transfusions unrelated to obstetric catastrophes among a predominantly Medicaid population.

An evidence-based definition of anemia for singleton, uncomplicated pregnancies.

BACKGROUND: The definition for anemia in pregnancy is outdated, derived from Scandinavian studies in the 1970's to 1980's. To identity women at risk of blood transfusion, a common cause of Severe Maternal Morbidity, a standard definition of anemia in pregnancy in a modern, healthy United States cohort is needed. OBJECTIVE: To define anemia in pregnancy in a United States population including a large county vs. private hospital population using uncomplicated patients. MATERIALS AND METHODS: Inclusion criteria were healthy women with the first prenatal visit before 20 weeks. Exclusion criteria included preterm birth, preeclampsia, hypertension, diabetes, short interval pregnancy (<18 months), multiple gestation, abruption, and fetal demise. All women had iron fortification (Ferrous sulfate 325 mg daily) recommended. The presentation to care and pre-delivery hematocrits were obtained, and the percentiles determined. A total of 2000 patients were included, 1000 from the public county hospital and 1000 from the private hospital. Each cohort had 250 patients in each 2011, 2013, 2015, and 2018. The cohorts were compared for differences in the fifth percentile for each antepartum epoch. Student's t-test and chi-squared statistical tests were used for analysis, p-value of ≤0.05 was considered significant. RESULTS: In the public and private populations, 777 and 785 women presented in the first trimester while 223 and 215 presented in the second. The women at the private hospital were more likely to be older, Caucasian race, nulliparous, and present earlier to care. The fifth percentile was compared between the women in the private and public hospitals and were clinically indistinguishable. When combining the cohorts, the fifth percentile for hemoglobin/hematocrit was 11 g/dL/32.8% in the first trimester, 10.3 g/dL/30.6% in the second trimester, and 10.0 g/dL/30.2% pre-delivery. CONCLUSIONS: Fifth percentile determinations were made from a combined cohort of normal, uncomplicated pregnancies to define anemia in pregnancy. Comparison of two different cohorts confirms that the same definition for anemia is appropriate regardless of demographics or patient mix.

Natural history of postpartum hematocrit recovery in an urban, safety-net population.

BACKGROUND: Postpartum anemia is common after delivery, and postpartum blood transfusion is the leading indicator of severe maternal morbidity in the United States. Although hematologic changes during the antepartum period are well understood, little is known about postpartum hematologic changes. Therefore, we investigated the hematologic changes in the postpartum period in a large, contemporary cohort. OBJECTIVE: This study aimed to characterize hematologic recovery in the postpartum period and evaluate the effect of demographics, medical conditions, and pregnancy characteristics on the recovery. STUDY DESIGN: In a contemporary cohort of deliveries in 2019 at a single institution, the hematocrit of postpartum women before hospital discharge was compared with the hematocrit of women at the postpartum follow-up. Our population was composed of a predominantly Hispanic population at an urban, safety-net hospital. All women received a complete blood count on postpartum day 1 and a spun hematocrit at their postpartum follow-up visit in our hospital system. All women were scheduled for a routine postpartum visit 2 to 3 weeks after delivery. All deliveries of a live-born infant with available postpartum hematocrit before hospital discharge and at postpartum follow-up were included. Demographics and pregnancy characteristics, along with medical conditions, were evaluated. To evaluate an uncomplicated cohort, those with multiple gestation, preeclampsia with severe features, chronic hypertension, and diabetes mellitus were excluded in the secondary analysis. Statistical analysis included chi-square, paired Student t test, Student t test for independent groups, and analysis of variance. RESULTS: Of 12,456 deliveries, 9003 met the inclusion criteria. The average number of days from discharge to follow-up was 21.73±10.39 days. The average hematocrit levels were 30.77±3.61 before discharge and 38.70±3.61 at postpartum follow-up. From discharge to postpartum follow-up, the hematocrit levels increased by an average of 7.93±3.24. In the cohort without complications, the average increase in hematocrit levels was 8.19±3.09. The rise in hematocrit levels was significantly lower for those with chronic hypertension (6.9±3.6), diabetes mellitus (7.3±3.3), and preeclampsia with severe features (6.9±3.7). The severity of anemia influenced the rise in hematocrit levels in the postpartum period. In women with postpartum anemia (hematocrit<30%), the rise in hematocrit levels was 9.49±2.97 in the uncomplicated cohort. Postpartum hemorrhage did not influence the rise in postpartum hematocrit levels; women receiving blood transfusion had a greater rise in hematocrit levels (9.01±3.29). CONCLUSION: Our study establishes the natural course of hematologic recovery in the postpartum period, and we found that women with asymptomatic postpartum anemia may have a hematocrit level of 37% to 39% at their postpartum follow-up approximately 3 weeks after hospital discharge. Women with preexisting and obstetrical complications experienced less hematologic recovery and adapted more slowly to postpartum physiological changes.

Congenital Malformation Risk According to Hemoglobin A1c Values in a Contemporary Cohort with Pregestational Diabetes.

OBJECTIVE: The study aimed to evaluate the association between hemoglobin A1c values and likelihood of fetal anomalies in women with pregestational diabetes. STUDY DESIGN: Women with pregestational diabetes who delivered at a single institution that serves a nonreferred population from May 1, 2009 to December 31, 2018 were ascertained. Hemoglobin A1c values were obtained at the first prenatal visit. Women who delivered a singleton live- or stillborn infant with a major malformation as defined by European Surveillance of Congenital Anomalies criteria were identified. In infants with multiple system anomalies, each malformation was considered separately. Hemoglobin A1c values were analyzed categorically by using Mantel-Haenszel method and continuously with linear regression for trend for fetal anomalies. RESULTS: A total of 1,676 deliveries to women with pregestational diabetes were delivered at our institution, and hemoglobin A1c was assessed in 1,573 deliveries (94%). There were 129 deliveries of an infant with at least one major malformation, an overall anomaly rate of approximately 8%. Mean hemoglobin A1c concentration was significantly higher in pregnancies with anomalous infants, 9.3 ± 2.1% versus 8.0 ± 2.1%, and p <0.001. There was no difference in gestational age at the time hemoglobin A1c was obtained, 13 ± 8.3 versus 14 ± 8.7 weeks. Hemoglobin A1c was associated with increased probability of a congenital malformation. This reached 10% with a hemoglobin A1c concentration of 10%, and 20% with a hemoglobin A1c of 13%. Similar trends were seen when examining risk of anomalies by organ system with increasing hemoglobin A1c levels, with the greatest increase in probability for both cardiac and genitourinary anomalies. CONCLUSION: In women with pregestational diabetes, hemoglobin A1c is strongly associated with fetal anomaly risk. Data from a contemporary cohort may facilitate counseling and also highlight the need for preconceptual care and glycemic optimization prior to entry to obstetric care. KEY POINTS: · Infants of diabetic mothers had an 8% major anomaly rate.. · HbA1c of 10% in pregnancy associated with 10% anomaly rate.. · HbA1c of 13% in pregnancy associated with 20% anomaly rate.. · Preconceptual care is important to reduce prevalence..

Effects of acute beta-adrenergic antagonism on verbal problem solving in autism spectrum disorder and exploration of treatment response markers.

Autism spectrum disorder (ASD) is characterized by impairments in social communication as well as restricted, repetitive behaviors. Evidence suggests that some individuals with ASD have cognitive impairments related to weak central coherence and hyperrestricted processing. Reducing noradrenergic activity may improve aspects of network processing and thus improve cognitive abilities, such as verbal problem solving, in individuals with ASD. The present pilot study explores the effects of acute administration of the beta-adrenergic antagonist propranolol on verbal problem solving in adults and adolescents with ASD. In a within-subject crossover-design, 20 participants with ASD received a single dose of propranolol or placebo on one of two sessions in a double-blinded, counterbalanced manner. Verbal problem solving was assessed via an anagram task. Baseline measurements of autonomic nervous system functioning were obtained, and anxiety was assessed at baseline and following drug administration. Participants solved the anagrams more quickly in the propranolol condition, as compared to the placebo condition, suggesting a potential cognitive benefit of this agent. Additionally, we observed a negative linear relationship between response to propranolol on the anagram task and two measures of baseline autonomic activity, as well as a positive linear relationship between drug response and baseline anxiety. These relationships propose potential markers for treatment response, as propranolol influences both autonomic functioning and anxiety. Further investigation is needed to expand on the present single-dose psychopharmacological challenge and explore the observed effects of propranolol in a serial-dose setting.

Effects of propranolol on conversational reciprocity in autism spectrum disorder: a pilot, double-blind, single-dose psychopharmacological challenge study.

RATIONALE: Pharmacological intervention for autism spectrum disorder (ASD) is an important addition to treatment, yet currently available agents target co-morbid psychiatric concerns, such as aggression and irritability. Propranolol, a beta-adrenergic antagonist with anxiolytic effects, has been shown to improve verbal fluency and working memory in adults and adolescents with ASD in single-dose challenges. OBJECTIVES: The present pilot study explores the acute effects of propranolol on a measure of conversational reciprocity in this population. We also examined whether autonomic activity and anxiety moderate or mediate response to the drug, given relationships between these variables and ASD, as well as the drug's effects. METHODS: In a within-subject crossover design, 20 individuals with ASD received a single dose of propranolol or placebo during two sessions in a double-blinded, counterbalanced manner. After drug administration, participants performed a conversational reciprocity task by engaging in a short conversation with the researcher. Measurements of autonomic activity and anxiety were obtained before and after drug administration. RESULTS: Propranolol significantly improved performance on the conversational reciprocity task total [d = 0.40] and nonverbal communication domain scores when compared to the placebo condition. However, neither autonomic activity nor anxiety was significantly associated with drug response. CONCLUSIONS: Acute propranolol administration improved conversational reciprocity in ASD. Further exploration of these preliminary findings, as well as other potential treatment response predictors, with serial doses is warranted.